The use of administrative claims data for reporting of healthcare costs and utilization is a relatively new phenomenon in the 1990's. Cost pressures due to increasing medical costs have caused health plans and insurers to look for new ways to understand what the health care dollar is buying. Furthermore, demands from employer groups and other healthcare payers have spawned a “quality of care” movement that has incentivised health plans to publicly report various aspects of their care delivery (e.g., by producing HEDIS reports) and to seek accreditation from the National Committee for Quality Accreditation or other accrediting body. Claims data, or electronic records of services and products paid for by a health plan for its insured population, have been instrumental in providing the information needed for cost, utilization, and quality reporting.
Much of health plan reporting focuses on particular illnesses or procedures and thus utilizes mainly medical claims submitted by physicians and facilities such as hospitals. Pharmacy claims, however, remain a largely untapped resource for analysis. Pharmacy claims have been used in certain quality of care analyses, such as identifying beta blocker usage for patients who have had heart attacks. Pharmacy claims have also been used to identify patients with particular diseases, such as diabetes. However, pharmacy claims data have not been used in a broad way to supplement—or even replace—analyses using medical claims data. The main reason for this is the fact that pharmacy claims do not contain diagnosis codes or any other information that would indicate why the drug was prescribed for a particular patient. Thus using pharmacy claims in various types of analysis requires one or more clinicians to manually determine, for each drug, all the diseases the drug is used to treat. This process is not feasible due to the time and resource constraints for most analytic needs.
Given these resource constraints, there is a need for a comprehensive, organized system that identifies the disease related uses for all drugs. Optimally, this system would be easy for health plans, large employers, or any other company with large claims databases to implement and maintain. The optimal system also would be updated periodically to provide information on the newest drugs approved by the FDA. The present invention was designed with these goals in mind.